Provider Demographics
NPI:1316448244
Name:WALKER, TERESA RAE (LMSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:RAE
Last Name:WALKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N 3RD AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6367
Mailing Address - Country:US
Mailing Address - Phone:208-232-5622
Mailing Address - Fax:208-233-4639
Practice Address - Street 1:151 N 3RD AVE STE 110
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6367
Practice Address - Country:US
Practice Address - Phone:208-232-5622
Practice Address - Fax:208-233-4639
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-37201104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker